TRANSITIONAL ADJUSTMENT
OF NOVICE NURSES
TO THE WORLD OF CLINICAL PRACTICE
A Thesis
Presented to the Faculty of the
Graduate of Nursing
In Partial Fulfillment of the Requirement
For the Degree Master of Science in Nursing
Major in Nursing Administration
2016
CHAPTER I
INTRODUCTION
Background of the Study
Transition is a changeover that affects the nursing profession. Transition is
defined as the process or an instance of passing from one form, state or stage to another
and the inner psychological process people go through to come to terms with the new
situation, as they let go of the way things used to be and reorient themselves to the way
that things are now. It is also an event, or non-event that results in changed
relationships, routines, assumptions, and roles.
Nursing is one of the most challenging professions and in the present clinical
practice the demand is requiring the professional nurse to be critical thinker, confident
and proficient when caring for patients. The combination of a demanding healthcare
system, intricate patient scenarios and the must for interpersonal relationships between
healthcare professionals can emerge the reality-shock that results to transitional
adjustment during their journey as novice nurses. “It seems that the transition into a new
professional role follows a predetermined pattern that all newcomers have to go
through, regardless of extensive efforts to facilitate the process” (Andersson & Edberg,
2010).
The transition from nursing student to professional nurse can be exciting, stressful
and challenging. As a novice nurse, some are beginning to experience transition. New
nurses are faced with a challenging work environment which shows their limited
clinical experience that may affect their performance in clinical practice according to
Rudmana, Gustavssona, Ehrenbergb, Boströmc, Wallincm 2012. Novice nurse are still
preoccupied during unanticipated clinical situations where assessing, diagnosing,
planning interventions, and carrying out skills still requires assistance. They often
shows hesitance in communicating to other healthcare professional during clinical
scenarios. New nurses experience unusual, challenging and unpleasant incident that
they may be unprepared to handle (Steen, Gould, Rungruber, & Hill, 2011).
Transition can diminish the morale and job satisfaction of novice nurses leading
to loss of self-belief and intention to leave the profession. During the 4th and 6th
months of working in the hospital new nurses felt dissatisfied due to increase workloads
and too much responsibility, scheduling and lack of support from colleagues, managers
and administration according to the study of Twibell, St. Pierre, Johnson, Barton, Davis,
Kidd, and Rook, 2012.
There are 9,114 new nurses that passed the Nursing Licensure Examination this
November 2015 (PRC, 2016) that added to 200,000 unemployed nurses (AHW, 2015).
According to a survey reported by the International Council of Nursing, the overall
nurse turnover rate within the first year of employment in Taiwan was about 28%.
Regionally, the Taipei City Nursing Board in Taiwan reported that the turnover rate of
new graduate nurses during the first year of employment was 57.7% and turnover was
at its peak of 32.1% within the first 3 months of employment. It has been estimated that
the United States (U.S.) will experience a growth of registered nurses (RNs) by 22%
from 2008 to 2018 (Bureau of Labor Statistics, 2011). According to data collected from
a new graduate hiring survey conducted by CINHC from January 2009 to March 2010,
43% of nursing graduates in California currently are not working as RNs (CINHC,
2010).
This study is made based on the researcher’s experience during transition in the
clinical practice as a novice nurse and observation from newly qualified nurses. In the
first six months to one year of employment it has been shown that experiencing
transition has a significant impact on novice nurses because they undergo a stressful
unsatisfying job that will affect their future career directions. The first year of practice
is an important confidence-building phase for nurses and yet many new graduate
nurses are experiencing this that would lead them to leave the profession as a result of
transition during their exposure to workplace. Therefore, this study aims to know the
factors that influences the transitional adjustment experienced by novice nurses and to
provide a structured transition or preceptorship program to enhance professional
development. Hatler, Stoffers, Kelly, Redding, and Carr (2011) explain, “a thoughtful,
systematic transition program can significantly improve retention and productivity”.
To optimize their ability to move in the course of transition process confidently and
effectively that would support to attenuate the reality and experienced by the novice
nurses in their first year to clinical practice.
Statement of the Problem
The study seeks to analyze role transition of novice nurses into clinical practice;
specifically this research aims to answer the following questions:
1. What is the demographic profile of the research participant in terms of:
a. Age
b. Gender
c. Clinical Area of Assignment
d. Months of Experience
e. Date Graduated
2. What are the factors that influence the transitional adjustment of novice nurses to
clinical practice?
3. Is there a significant relationship between participant’s demographic data and
factors that influence transitional adjustment by novice nurses?
Hypotheses
The researcher tested the following hypothesis in this study at 0.05 level of significance.
There is no significant relationship between participant’s demographic data and
factors that result’s to transition by novice nurses?
Theoretical Framework
The transition stage model presented in this study by Duchscher, 2007
incorporates the journey of new nurses progressed through the stages of doing, being and
knowing. Doing is the initial stage of role transition for novice nurses that happened for
the first 3 months on clinical practice. They experience full of ups and downs, clinical
dilemma and they are task oriented and worked through the process of learning,
performing, concealing, adjusting and accommodating. The next stage is being, for 4 to 7
months the process of searching, examining, doubting, questioning and revealing was
starting. The physical exhaustion, intimidation to colleagues, physician and co-employees
was experienced. In this stage some of novice nurses realized and decided to quit job and
change their career. Knowing is the final stage of role transition that encompasses the
process of separating, recovering, exploring, critiquing and accepting. The novice nurses
for 8 to 12 months had reached a relatively stable level of comfort and confidence with
their roles, responsibilities.
The Novice to Expert Theory by Patricia Benner (1984) was another theoretical
perspective used in this study that explains on how nurses acquire skills through
instruction and practice that is derived from the Dreyfus Model of Skill Acquisition that is
applied to the nursing profession. Benner described the process of clinical judgment and
skill development at five levels of proficiency: novice, advanced beginner, competent,
proficient and expert. Every nurse moves along a continuous process as she or he learns
and gain experience at his or her own pace and move from one identified stage to another,
depending on the clinical knowledge and experience that they encounter. Each stage has
its own description of behaviors, knowledge, and ability to work with patients and
families. The novice stage consists of the beginner nurse who learns to follow rules to
perform tasks, has no experience, and needs to be told what to do. In the next stage the
advanced beginner has more experience but principles are based on past experiences that
have developed. The third stage, competent, is a nurse with 2 to 3 years of experience,
who has obtained more analytical and abstract manners in thinking. The fourth stage is
proficient, which the nurse sees everything as a whole, learned from past experiences and
knows what to expect given the situation. The last stage is expert, this is when the nurse
no longer needs the rules, has intuition, and is more proficient.
Conceptual Paradigm
INPUT PROCESS OUTPUT
Demographic Profile of
participants: Proposed Action Plan:
Factors experiencing by To develop or enhance a
Age novice nurses that results structured program that
Gender to transition. would help novice
Clinical Area of Assignment nurses during their
Months of experience transition in the clinical
Date Graduated practice.
Figure 2. Schematic Diagram on the conduct of the study
Using Ludwig’s System’s theory, figure 2 illustrates the research paradigm of the
study. The researchers firstly identified the participants’ demographic profile, factors
experiencing by the participants that result to transition. On the other hand, the process
includes utilization of validated questionnaire as a tool for data collection to know the
factors that result to transition of novice nurses in clinical practice. Finally, as output, the
researchers have come up with proposed action plan to be consider for the enhancement of
Clinical Nursing Development Program of San Juan De Dios Educational Foundation Inc.
(Hospital)
Significance of the Study
The Significance of conducting this study is to develop and enhance a structured
program that would help novice nurses during their transition in the clinical practice of the
selected tertiary hospital. It is hoped that the clinical result of the study will be beneficial
to the following:
Novice Nurses, This study will be able to help novice nurses to cope up with transition
they are experiencing and to developed critical thinking, confidence and to be competent.
Hospital Administrators, The study will benefit the hospital in terms of increasing
turnover of novice nurses. This will be able to identify what would be the reason why
novice nurses are experiencing stages of transition and to develop a program that would
increase confidence and retain of nurses.
School Administrators, This study will be use as a baseline data for the plans of action. A
revision of curriculum or re-conceptualizing their program or subjects that will give
students may be considered in preparing them before clinical placement.
Students, This study will increase the student’s knowledge and will inspire them to do
similar studies. This can be a reference from their future researches.
Association of Deans of College in Nursing, This study will open awareness in
formulating program that would help students in preparation to clinical practice as
professionals.
Researchers, who will use this study for another research study about the transition
experienced by novice nurses. Through this paper, researchers may be able to develop and
propose coping processes that would help novice nurses.
Future Researchers, That will refer this study will also benefit and may gain insight from
this study to do similar studies regarding to the transition that is experiencing by novice
nurses. the more research that is conducted, the more professionals will recognize the
importance of this matter in relation to the nursing profession as a whole.
Scope and Limitation
This study is focused on transition experiencing by novice nurses in the clinical
practice. This was conducted in San Juan de Dios Educational Foundation Inc. that is a
private, non-stock, non-profit, joint institute of education and tertiary health sciences with
a 230 bed capacities operating by the Daughters of Charity within the City of Pasay,
Philippines from April 1 to June 30 2016.
Respondents of this study was limited to fifty (50) nurses currently employed as
probationary or regular staff nurses in the different areas of assignment of the selected
hospital.
Definition of Terms
The researchers based the following definitions according to its operational use in clinical
setting.
Clinical Practice- is working as a professional registered nurse in the hospital.
Transition – is a process of new role from a student to a professional registered nurse that
experience on entry to the world of clinical practice.
Novice Nurse – are newly professional registered nurses with no prior experience in the
clinical practice for 1 to 12 months.
CHAPTER II
REVIEW OF RELATED LITERATURE AND STUDIES
This chapter presents the different readings that are related to the study. It
encompasses the studies from local and foreign books and articles of authors whose
researches are recognized. Important concepts focused on theories and studies related to
transition experienced by novice nurse.
The transition from student to nurse has been studied over the past decade in two
waves. The first wave dealt with individual nurses’ response to the transition, and the
second wave evaluated institutionally based programs designed to support the transition.
The first group of studies used in-depth interviews and surveys to arrive at similar
findings: Initially, the new role was extremely stressful with many studies reporting
challenging conditions; however, gradually, role conflict was tempered over time by
developing competence, gaining confidence, and finding clinical support (Lavoi-
Tremblay et al., 2008).
The transition from student to nurse has been described as traumatic, confusing,
and shocking. The difficulties encountered by the graduates have led to the premature
termination of their first position, and sometimes they leave nursing altogether. To coach
new nurses in preparation for their first year of practice using an appreciative inquiry
framework, it focuses on the new graduates’ perspective of the processes that enabled
them to successfully integrate into their new role. (G. E. Chandler, 2012)
There is a growing concern about newly graduated nurses' (NGNs) readiness to
practice including claims that they are inadequately prepared to care for the high acuity
patients found in the acute care setting found that only 4% of were comfortable with their
skills and that it took up to 1 year for them to feel competent and confident with their
abilities. It is reported that NGNs feel shocked, unprepared, and overwhelmed with the
responsibility of the professional role. (L. Wiles, L. Simko and M. Schoessler, 2013)
New nurses described transition as having feelings of incompetence; having an
overwhelming sense of responsibility; being fearful of physicians; and finding difficulty
in organizing, prioritizing, and delegating. This high turnover can negatively influence
patient outcomes, staff morale, and work productivity. In addition, the organization bears
the burden of replacement costs and the process of rehiring new recruits. The authors
concluded that producing more nurses was one approach to the nursing shortage;
however, patient care deficiencies and a non supportive work environment should be
addressed as well (Bowles & Candela, 2005).
Graduate nurse transition from college to professional practice is an important
matter in a nurse's professional life. In many cases, this period is characterized by
unhealthy physical and mental reactions, loss of interest in one's profession, and
unacceptable caregiving. This study indicate that the participants were not well prepared
to assume their clinical roles, which in turn gives rise to other problems; to eliminate this
defect, the curriculum needs to be revised, proper training programs should accompany
the students' studies, and management in clinical environments recommended should be
improved in order to facilitate nurses' transition from college to practice. (V.
Zamanzadeh, 2015).
According to Doody, 2012, the absence of national graduate transitional guidelines
to support newly qualified nurses and the lack of national trainer guidelines for nurses
involved in the preceptorship of newly qualified nurses must be addressed. Having a
structured preceptoship program from education and health service institutions with
clinical, management and organizational skills will provide a difference through the
transition process. This would also foster a supportive work environment for newly
graduated nurse which influence their satisfaction, retention and improve patient care.
In UK, A preceptorship framework for newly registered nurses, midwives and
allied health professionals’ to set clear standards for preceptorship was developed by the
Department of Health (2010) to show recognition of the importance of the transition
period for healthcare professionals and a vital step towards easing the transition and
providing a formal support system for the graduate.
The training program improved students’ clinical competence. The stressful time
that was correlated with new graduate nurses’ intention to leave their job was between the
sixth and twelfth months after employment. (Ching-Yu Cheng et al., 2014)
Synthesis
The studies and related literature have helped the researcher in undertaking this
study. It was purely useful to this study that they provided a broader sense of
understanding about the transition of novice nurses into clinical practice. Various authors
stated that the transition from student to nurse during their first year in the clinical
practice was traumatic, stressful, there’s a feeling of incompetence and having a lack of
support from the institution that would lead them in leaving their job or even their
profession.
There are suggestions from other authors that a training or preceptorship program
must be develop and implemented during the last year of the nursing student and during
the orientation phase in the clinical practice to improve patient care, increase job
satisfaction and to decrease turnover.
CHAPTER III
RESEARCH METHODS
This chapter of the study provides the blueprint of the entire research plan. It
covers discussion on the design chosen in this study, the population frame and sample
respondents, the instruments used as well as the manner it was administered. This also
describes the overall procedure on how this study was conducted.
RESEARCH DESIGN
The research design is the set of logical steps and an overall plan taken by the
researcher to answer the research question. The researcher will specify which specific
design will be used to minimize the bias and enhance the result. It will also indicate how
often data will be collected, what types of comparisons will be made, ad where the study
will take place. (Polit & Beck, 2010). This study utilized the descriptive correlational
research method which focuses on understanding the interrelationships among variables
of interest without researcher intervention. (Polit & Beck, 2010). The researcher would
like to uncover the link between participant’s demographic data, stages of transition and
factors that result in transition by novice nurses.
Population Frame and Sampling Technique
The researcher used the whole population available during the gathering of data.
All staff nurses, who currently working in selected tertiary hospital in Metro Manila
regardless of their area of assignment specifically San Juan de Dios Educational
Foundation, Inc. (Hospital) was utilized as respondents. The study was conducted in all
section of the institution which consists of Ambulatory Care Section, Adult Care
Section, Mother and Child Section and Special Care Section.
The main focus of the research study is to identify participant’s demographic
data, stages of transition and factors that result in transition by novice nurses. Hence,
the sampling technique that was used in this study is a non probability, purposive
sampling wherein the researcher purposely select participants based on personal
judgment particularly knowledgeable about the issues of the study. (Polit & Beck,
2010). The criteria in choosing a respondent are the following 1) Should be a newly
registered nurse with 1-12 months clinical experience; 2) should be employed as
probationary or regular staff nurse. A total of thirty (50) samples are included in this
study.
Research Instrumentation
The investigator adopted Casey-Fink Graduate Nurse Experience Survey® 2006
to measure skill and competence. The CFGNES® has a reliability factor of .71 to .90
with an internal consistency of α = .89. The survey consists of five sections:
demographics, skills/procedures performance, comfort and confidence, job satisfaction,
and five open-ended questions that allowed the residents to express their experiences.
Permission was obtained for both the Casey-Fink Graduate Nurse Experience Survey®.
Data Gathering Procedure
The data was gathered based on the following procedures:
Administrative Clearance
A letter of permission from the Dean of the Graduate School of Concordia
College was prepared which provided the approval for conducting the study in the chosen
institution. Likewise, Before conducting the study, the researcher will submit letters of
approval to the Vice President for Health Services, Director of Medicine, Assistant
Director of Medicine, Director of the Nursing Service Division, Assistant Director
Nursing Service Division, Training Coordinator for Nursing, Head of the Research
Committee. The researcher will also accomplish forms for the approval of the
Institutional Review Board of SJDEFI (Hospital). The researcher presented this letter
personally.
Furthermore, informed consent was obtained to inform the objectives of the study
as well as the interpretation of the possible score result and also included the assurance of
privacy of the data that would be gathered by the researcher. Questionnaires were
personally distributed to the respondents by the researcher assured of a one hundred
percent (100%) retrieval. The data was encoded and processed through the use of proper
statistical tool.
Statistical Treatment
The Statistical Treatment of data posts information about the statistical tests that
were utilized to answer the problems in the statement of the problem. In lieu of this, the
researcher used Weighted Mean, Grand Mean and Independent t-test. This will be tested
through the use of SPSS (Statistical Product and Service Solutions) version 20 software
program for the validity and reliability. Data gathered were examined, tabulated and
converted to percentages and will undergo test for normality to know if it is under
parametric or non-parametric. If it is parametric, Independent t-test will be applied and if
it is non-parametric, Mann-Whitney Test will be used.
